Texas Statutes
Title 8 - Health Insurance and Other Health Coverages
Subtitle C - Managed Care

Section 1271.051. Evidence of Coverage: Contract and Certificate Requirements - Sec. 1271.051. EVIDENCE OF COVERAGE: CONTRACT AND CERTIFICATE REQUIREMENTS. (a)...

Section 1271.052. Information About Benefits and Limitations - Sec. 1271.052. INFORMATION ABOUT BENEFITS AND LIMITATIONS. An evidence of...

Section 1271.053. Information About Obtaining Services - Sec. 1271.053. INFORMATION ABOUT OBTAINING SERVICES. An evidence of coverage...

Section 1271.054. Information About Complaints and Appeals - Sec. 1271.054. INFORMATION ABOUT COMPLAINTS AND APPEALS. (a) An evidence...

Section 1271.055. Out-of-Network Services - Sec. 1271.055. OUT-OF-NETWORK SERVICES. (a) An evidence of coverage must...

Section 1271.056. Unfair or Deceptive Provisions and Statements Prohibited - Sec. 1271.056. UNFAIR OR DECEPTIVE PROVISIONS AND STATEMENTS PROHIBITED. An...

Section 1271.057. Discretionary Clauses Prohibited - Sec. 1271.057. DISCRETIONARY CLAUSES PROHIBITED. (a) An evidence of coverage...

Subchapter C. Commissioner Approval

Section 1271.101. Approval of Form of Evidence of Coverage or Group Contract - Sec. 1271.101. APPROVAL OF FORM OF EVIDENCE OF COVERAGE OR...

Section 1271.102. Procedures for Approval of Form of Evidence of Coverage or Group Contract; Withdrawal of Approval - Sec. 1271.102. PROCEDURES FOR APPROVAL OF FORM OF EVIDENCE OF...

Section 1271.103. Withdrawal of Approval of Form - Sec. 1271.103. WITHDRAWAL OF APPROVAL OF FORM. (a) After notice...

Section 1271.104. Information Required by Commissioner - Sec. 1271.104. INFORMATION REQUIRED BY COMMISSIONER. The commissioner may require...

Subchapter D. Certain Benefits Required

Section 1271.151. Provision of Basic Health Care Services - Sec. 1271.151. PROVISION OF BASIC HEALTH CARE SERVICES. A health...

Section 1271.152. Standards for Basic Health Care Services - Sec. 1271.152. STANDARDS FOR BASIC HEALTH CARE SERVICES. The commissioner...

Section 1271.153. Periodic Health Evaluations - Sec. 1271.153. PERIODIC HEALTH EVALUATIONS. (a) The basic health care...

Section 1271.154. Well-Child Care From Birth - Sec. 1271.154. WELL-CHILD CARE FROM BIRTH. (a) In this section,...

Section 1271.155. Emergency Care - Sec. 1271.155. EMERGENCY CARE. (a) A health maintenance organization shall...

Section 1271.156. Benefits for Rehabilitation Services and Therapies - Sec. 1271.156. BENEFITS FOR REHABILITATION SERVICES AND THERAPIES. (a) If...

Section 1271.157. Non-Network Facility-Based Providers - Sec. 1271.157. NON-NETWORK FACILITY-BASED PROVIDERS. (a) In this section, "facility-based...

Section 1271.158. Non-Network Diagnostic Imaging Provider or Laboratory Service Provider - Sec. 1271.158. NON-NETWORK DIAGNOSTIC IMAGING PROVIDER OR LABORATORY SERVICE PROVIDER....

Subchapter E. Choice of Primary Care Physician for Certain Enrollees

Section 1271.201. Designation of Specialist as Primary Care Physician - Sec. 1271.201. DESIGNATION OF SPECIALIST AS PRIMARY CARE PHYSICIAN. (a)...

Section 1271.202. Appeal - Sec. 1271.202. APPEAL. If a health maintenance organization denies a...

Section 1271.203. Effective Date of Designation - Sec. 1271.203. EFFECTIVE DATE OF DESIGNATION. (a) The effective date...

Subchapter F. Schedule of Charges

Section 1271.251. Approval of Formula or Method for Computing Schedule of Charges - Sec. 1271.251. APPROVAL OF FORMULA OR METHOD FOR COMPUTING SCHEDULE...

Section 1271.252. Consideration of Individual Health Status Prohibited - Sec. 1271.252. CONSIDERATION OF INDIVIDUAL HEALTH STATUS PROHIBITED. The charges...

Section 1271.253. Information Required by Commissioner - Sec. 1271.253. INFORMATION REQUIRED BY COMMISSIONER. The commissioner may require...

Subchapter G. Continuation of Coverage, Conversion Contracts, and Renewal

Section 1271.301. Entitlement to Continuation of Group Coverage - Sec. 1271.301. ENTITLEMENT TO CONTINUATION OF GROUP COVERAGE. (a) In...

Section 1271.302. Request for Continued Coverage; Deadline - Sec. 1271.302. REQUEST FOR CONTINUED COVERAGE; DEADLINE. An enrollee must...

Section 1271.303. Payment for Continued Coverage - Sec. 1271.303. PAYMENT FOR CONTINUED COVERAGE. (a) An enrollee electing...

Section 1271.304. Termination of Continued Coverage - Sec. 1271.304. TERMINATION OF CONTINUED COVERAGE. Group continued coverage under...

Section 1271.306. Conversion Contracts - Sec. 1271.306. CONVERSION CONTRACTS. (a) A health maintenance organization may...

Section 1271.307. Renewability of Coverage: Individual Health Care Plans and Conversion Contracts - Sec. 1271.307. RENEWABILITY OF COVERAGE: INDIVIDUAL HEALTH CARE PLANS AND...

Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization

Subchapter A. General Provisions

Section 1272.001. Definitions - Sec. 1272.001. DEFINITIONS. (a) In this chapter: (1) "Delegated entity"...

Section 1272.002. Compliance of Limited Provider Network or Delegated Entity With Certain Legal Requirements - Sec. 1272.002. COMPLIANCE OF LIMITED PROVIDER NETWORK OR DELEGATED ENTITY...

Subchapter B. Delegation Agreements

Section 1272.051. Applicability of Subchapter - Sec. 1272.051. APPLICABILITY OF SUBCHAPTER. This subchapter does not apply...

Section 1272.052. Delegation Agreement Required - Sec. 1272.052. DELEGATION AGREEMENT REQUIRED. (a) A health maintenance organization...

Section 1272.053. Monitoring Plan - Sec. 1272.053. MONITORING PLAN. A delegation agreement required by Section...

Section 1272.054. Requirements for Termination Without Cause - Sec. 1272.054. REQUIREMENTS FOR TERMINATION WITHOUT CAUSE. A delegation agreement...

Section 1272.055. Collection of Payments - Sec. 1272.055. COLLECTION OF PAYMENTS. A delegation agreement required by...

Section 1272.056. Compliance With Statutory and Regulatory Requirements - Sec. 1272.056. COMPLIANCE WITH STATUTORY AND REGULATORY REQUIREMENTS. A delegation...

Section 1272.057. Examination by Commissioner - Sec. 1272.057. EXAMINATION BY COMMISSIONER. A delegation agreement required by...

Section 1272.058. Information Relating to Delegated Third Party - Sec. 1272.058. INFORMATION RELATING TO DELEGATED THIRD PARTY. A delegation...

Section 1272.059. Contracts With Delegated Third Party - Sec. 1272.059. CONTRACTS WITH DELEGATED THIRD PARTY. A delegation agreement...

Section 1272.060. Utilization Review - Sec. 1272.060. UTILIZATION REVIEW. A delegation agreement required by Section...

Section 1272.061. Rights and Duties of Delegated Entity and Health Maintenance Organization - Sec. 1272.061. RIGHTS AND DUTIES OF DELEGATED ENTITY AND HEALTH...

Section 1272.062. Information to Be Provided by Delegated Entity to Health Maintenance Organization - Sec. 1272.062. INFORMATION TO BE PROVIDED BY DELEGATED ENTITY TO...

Section 1272.063. Enrollee Complaints - Sec. 1272.063. ENROLLEE COMPLAINTS. (a) A delegation agreement required by...

Section 1272.064. Rules - Sec. 1272.064. RULES. The commissioner may adopt rules as necessary...

Subchapter C. Information Reporting to Delegated Entity

Section 1272.101. Applicability of Subchapter - Sec. 1272.101. APPLICABILITY OF SUBCHAPTER. This subchapter does not apply...

Section 1272.102. Reporting Required - Sec. 1272.102. REPORTING REQUIRED. (a) The commissioner shall determine the...

Section 1272.103. Rules - Sec. 1272.103. RULES. The commissioner may adopt rules as necessary...

Subchapter D. Reserve Requirements

Section 1272.151. Applicability of Subchapter - Sec. 1272.151. APPLICABILITY OF SUBCHAPTER. This subchapter does not apply...

Section 1272.152. General Reserve Requirements - Sec. 1272.152. GENERAL RESERVE REQUIREMENTS. (a) A delegated network shall...

Section 1272.153. Reserve Requirements for Medical Care and Hospital or Institutional Services - Sec. 1272.153. RESERVE REQUIREMENTS FOR MEDICAL CARE AND HOSPITAL OR...

Section 1272.154. Reserve Requirements for Prescription Drugs - Sec. 1272.154. RESERVE REQUIREMENTS FOR PRESCRIPTION DRUGS. A delegated network...

Section 1272.155. Form of Reserves - Sec. 1272.155. FORM OF RESERVES. The reserves required under this...

Section 1272.156. Escrow Account - Sec. 1272.156. ESCROW ACCOUNT. (a) A delegated network required to...

Subchapter E. Compliance

Section 1272.201. Applicability of Subchapter - Sec. 1272.201. APPLICABILITY OF SUBCHAPTER. This subchapter does not apply...

Section 1272.202. Notice of Noncompliance or Hazardous Operating Condition - Sec. 1272.202. NOTICE OF NONCOMPLIANCE OR HAZARDOUS OPERATING CONDITION. (a)...

Section 1272.203. Response to Notice - Sec. 1272.203. RESPONSE TO NOTICE. A delegated entity shall respond...

Section 1272.204. Cooperation of Health Maintenance Organization - Sec. 1272.204. COOPERATION OF HEALTH MAINTENANCE ORGANIZATION. A health maintenance...

Section 1272.205. Examination by Department; Report - Sec. 1272.205. EXAMINATION BY DEPARTMENT; REPORT. (a) On receipt of...

Section 1272.206. Response to Department Report; Corrective Plan - Sec. 1272.206. RESPONSE TO DEPARTMENT REPORT; CORRECTIVE PLAN. The delegated...

Section 1272.207. Request for Corrective Action - Sec. 1272.207. REQUEST FOR CORRECTIVE ACTION. The department may request...

Section 1272.208. Authority of Commissioner to Issue Order - Sec. 1272.208. AUTHORITY OF COMMISSIONER TO ISSUE ORDER. (a) Regardless...

Section 1272.209. Public Documents - Sec. 1272.209. PUBLIC DOCUMENTS. (a) Except as provided by Subsection...

Section 1272.210. Record of Complaints; Report - Sec. 1272.210. RECORD OF COMPLAINTS; REPORT. (a) The department shall:...

Section 1272.211. Rules - Sec. 1272.211. RULES. The commissioner may adopt rules as necessary...

Subchapter F. Penalties

Section 1272.251. Applicability of Subchapter - Sec. 1272.251. APPLICABILITY OF SUBCHAPTER. This subchapter does not apply...

Section 1272.252. Suspension or Revocation of License of Third-Party Administrator or Utilization Review Agent - Sec. 1272.252. SUSPENSION OR REVOCATION OF LICENSE OF THIRD-PARTY ADMINISTRATOR...

Section 1272.253. Sanctions and Penalties Against Health Maintenance Organization - Sec. 1272.253. SANCTIONS AND PENALTIES AGAINST HEALTH MAINTENANCE ORGANIZATION. The...

Section 1272.254. Contractual Penalties Required - Sec. 1272.254. CONTRACTUAL PENALTIES REQUIRED. A health maintenance organization by...

Section 1272.255. Rules - Sec. 1272.255. RULES. The commissioner may adopt rules as necessary...

Subchapter G. Provision of Services by Limited Provider Network or Delegated Entity

Section 1272.301. Access to Out-of-Network Services - Sec. 1272.301. ACCESS TO OUT-OF-NETWORK SERVICES. (a) A contract between...

Section 1272.302. Continuity of Care - Sec. 1272.302. CONTINUITY OF CARE. (a) In this section, "special...

Chapter 1273 - Point-of-Service Plans

Subchapter A. Blended Contracts

Section 1273.001. Definitions - Sec. 1273.001. DEFINITIONS. In this subchapter: (1) "Blended contract" means...

Section 1273.002. Point-of-Service Plan - Sec. 1273.002. POINT-OF-SERVICE PLAN. An insurer may contract with a...

Section 1273.003. Blended Contract - Sec. 1273.003. BLENDED CONTRACT. (a) A health maintenance organization and...

Section 1273.004. Limited Benefits and Services; Cost-Sharing Provisions - Sec. 1273.004. LIMITED BENEFITS AND SERVICES; COST-SHARING PROVISIONS. Indemnity benefits...

Section 1273.005. Rules - Sec. 1273.005. RULES. The commissioner may adopt rules to implement...

Subchapter B. Availability of Health Benefit Coverage Options

Section 1273.051. Definitions - Sec. 1273.051. DEFINITIONS. In this subchapter: (1) "Employee" means an...

Section 1273.052. Offer of Coverage Through Non-Network Plan Required - Sec. 1273.052. OFFER OF COVERAGE THROUGH NON-NETWORK PLAN REQUIRED. (a)...

Section 1273.053. Coverage Options - Sec. 1273.053. COVERAGE OPTIONS. The coverage required to be offered...

Section 1273.054. Premium for Coverage Options - Sec. 1273.054. PREMIUM FOR COVERAGE OPTIONS. The premium for coverage...

Section 1273.055. Cost-Sharing Provisions - Sec. 1273.055. COST-SHARING PROVISIONS. (a) Different cost-sharing provisions may be...

Section 1273.056. Exceptions - Sec. 1273.056. EXCEPTIONS. This subchapter does not apply to: (1)...

Section 1273.057. Rules - Sec. 1273.057. RULES. The commissioner shall adopt rules necessary to...

Chapter 1274 - Electronic Transmission of Eligibility and Payment Status

Section 1274.001. Definitions - Sec. 1274.001. DEFINITIONS. In this chapter: (1) "Enrollee" means an...

Section 1274.0015. Exemption - Sec. 1274.0015. EXEMPTION. This chapter does not apply to a...

Section 1274.002. Transmission of Enrollee Eligibility and Payment Status - Sec. 1274.002. TRANSMISSION OF ENROLLEE ELIGIBILITY AND PAYMENT STATUS. (a)...

Section 1274.003. Certain Charges Prohibited - Sec. 1274.003. CERTAIN CHARGES PROHIBITED. A health benefit plan issuer...

Section 1274.004. Rules - Sec. 1274.004. RULES. (a) The commissioner shall adopt rules as...

Section 1274.005. Waiver of Certain Provisions for Certain Federal Plans - Sec. 1274.005. WAIVER OF CERTAIN PROVISIONS FOR CERTAIN FEDERAL PLANS....

Chapter 1275 - Balance Billing Prohibitions and Out-of-Network Claim Dispute Resolution for Certain Plans

Subchapter A. General Provisions

Section 1275.001. Definitions - Sec. 1275.001. DEFINITIONS. In this chapter: (1) "Enrollee" means an...

Section 1275.002. Applicability of Chapter - Sec. 1275.002. APPLICABILITY OF CHAPTER. This chapter applies to a...

Section 1275.003. Balance Billing Prohibition Notice - Sec. 1275.003. BALANCE BILLING PROHIBITION NOTICE. (a) The administrator of...

Section 1275.004. Out-of-Network Claim Dispute Resolution - Sec. 1275.004. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION. Chapter 1467 applies to...

Subchapter B. Payments for Certain Services; Balance Billing Prohibitions

Section 1275.051. Emergency Care Payments - Sec. 1275.051. EMERGENCY CARE PAYMENTS. (a) In this section, "emergency...

Section 1275.052. Out-of-Network Facility-Based Provider Payments - Sec. 1275.052. OUT-OF-NETWORK FACILITY-BASED PROVIDER PAYMENTS. (a) In this section,...

Section 1275.053. Out-of-Network Diagnostic Imaging Provider or Laboratory Service Provider Payments - Sec. 1275.053. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER OR LABORATORY SERVICE PROVIDER...

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Texas Statutes Title 8 - Health Insurance and Other Health Coverages Subtitle C - Managed Care

Texas Statutes
Title 8 - Health Insurance and Other Health Coverages
Subtitle C - Managed Care